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[] SCHIZOPHRENIA 1 [] INTRODUCTION Before you start to read this topic, try to imagine what might patient with this illness experience . Schizophrenic patients known about they are seeing things or hearing voices. For example, imagine that somebody calling your name inside your room and you are certain that no one is inside the house except you only ! Or seeing some one is not even at your local area setting beside you .. and others keep staring at you when you talk with your imaginary friend ? Do you find it scary? bizarre? Now what does schizophrenic patient really feels and how does it shape their life on many aspects , mental , social and physical , and what is the nursing expected to do when dealing with schizophrenic patients , that’s what will be illustrated in this project. 2 [] 1.1-Definitions “Schizophrenia is the most chronic and disabling of the severe mental disorders, associated with abnormalities of brain structure and function, disorganized speech and behavior, delusions, and hallucinations. It is sometimes called a psychotic disorder or a psychosis”. “psychotic disorder , marked by sever and often irreversible deterioration in personality , affect , communication , and intellectual functions”. “it’s a disorder that lasts for at least 6 months and includes at least 1 month of activephase symptoms (i.e., two [or more] of the following: delusions ,hallucination ,disorganized speech , grossly disorganized or catatonic behavior , negative symptoms) ”. 1.2-Medical background : 1.2A-First , what is the meaning of the term “ schizophrenia “ ? [Schizophrenia from the Greek roots schizein "to split" and phrēn,phren- "mind" ] Its diagnosis termed by Eugen Bleuler. (see Figure 1) In 1908, Eugen Bleuler, a Swiss psychiatrist, introduced the term schizophrenia. which replaced the term dementia praecox, used by Emil Kraepelin (1896). Kraepelin viewed this disorder as a deteriorating organic disease. Bleuler viewed it as a serious disruption of the mind, a “splitting of the mind.” In 1948. According to the DSM-IV , schizophrenia classified under the section of “SCHIZOPHRENIA AND OTHER PSYCHOTIC DISORDERS”. Fig.1 Eugen Bleuler. 3 [] 1.2B-Description When we talk about the symptoms we should keep in mind that not all the patient share the same signs\symptoms of the disease, in addition , ones symptoms could or may change over The Schizophrenia Prodrome time. Tonya White, M.D., Afshan Also doctors recognized subtypes but no single Anjum, M.D., and S. Charles Schulz, M.D. A 13-year-old girl, classification system has gained universal currently in the eighth grade and acceptance , also the DSM-IV-TR acknowledges with a history of attention deficit hyperactivity disorder, was that its present classification of subtypes is not brought by her mother to a fully satisfactory for either clinical or research university-affiliated outpatient purposes, and states that “alternative sub typing psychiatric clinic after a gradual decline in her academic schemes are being actively investigated.” performance was noted. She had a Symptoms of schizophrenia can appears at any previous history of receiving grades of B and C in all her time, after age of 6 or 7 , even under 5 but its very classes, but currently she was very rare , and in some over 80 years old also . getting Ds and Fs. At age 8 years The onset can be sudden or gradual . often it goes she had begun receiving stimulant medication, with some benefit. She undetected for about 2 to 3 years after the onset of had tasted alcohol in the past but diagnosable symptoms . denied current use. She had also used marijuana a half-dozen times. The patient may have had panic attacks, social She reported having a small phobia, or substance abuse problems, any of which number of close friends. Although can complicate the process of diagnosis. she said that there were no recent changes in her peer relationships, There is no “typical” pattern or course of the her parents claimed that she had disorder following the first acute episode. The been withdrawn and had appeared sad and that at times they needed patient may never have a second psychotic to prompt her to take a shower. episode; others have occasional episodes over the She had a maternal aunt with course of their lives but can lead fairly normal lives bipolar affective disorder and a great uncle who had been otherwise, some patients remain chronically ill . 1.2C-Prodromal symptoms : Simply , prodromal symptoms means “signs and symptoms that precede the actual onset of the disorder and the time interval between the first manifestation of the disorder and the first appearance of the full picture.” Its involve mixture of behaviors like : angry outbursts withdrawal from social activities loss of attention to personal hygiene and grooming, anhedonia (loss of interest and joy ) and other unusual behaviors like suspicion’s. 4 institutionalized for unknown reasons. During the clinical interview, she was dressed in Goth attire, including a black T-shirt with images of letters dripping blood; she had dyed black hair. Her affect was blunted but was slightly more animated when her parents left the room. She denied thoughts of suicide. She reported occasionally hearing whispering voices calling her name and saying that she is worthless. She also reported the belief that her friends did not like her as much as they had. Her mother, who recently met a parent of a child with schizophrenia, posed the question of whether her daughter has schizophrenia.?** [] 1.3-Risk factors \ etiology : Recent research suggests that schizophrenia involves problems with brain chemistry and brain structure. However, no single cause has been identified to account for all cases of schizophrenia. Scientists are currently investigating possible factors contributing to the development of schizophrenia. These factors discussed in the form of hypotheses or theory such as : -GENTIC THEORY : What is clear that schizophrenia tend to be inherited ,for example studies revealed that monozygotic twins have the highest concordance rates for schizophrenia ,meaning that they are more likely to both have schizophrenia if one of them has it, compared to people who share less genetic material -Biochemical and Biological Theory : Increased dopamine level and brain dysfunction or structure abnormities, but it does not really seems to be either a cause or consequence of the disorder. - Environmental or Cultural Theory Theorists also believe that persons who come from low socioeconomic areas or singleparent homes in deprived areas are not exposed to situations in which they can achieve or become successful in life. Thus they are at risk for developing schizophrenia. And there is several other factors and theory to the etiology of this disorder : -Vitamin Deficiency Theory -Perinatal Theory 5 [] 2.1-Diagnosis and finding: Clinical diagnosis is developed on historical information and thorough mental status examination. No laboratory finding have been identified that are diagnostic for schizophrenia , studies between groups of schizophrenic patients and other appropriate matched control subject shows results on these exams : 1. Neuro-imaging exam. 2. Neuro-psychological exam. 3. Neuro-physiological exam . Neuro-imaging : -Enlargement of the lateral ventricles.fig.2 -decreased brain tissue evidenced by widened cortical sulci and decreased gray and white matter. -decreased blood flow for neural activity . Neuro-psychological : -deficits in memory attention psychomotor ability. Neuro-physiological: -deficits in perception and processing sensory stimuli. -abnormal smooth pursuit. -saccadic eye movement . -slowed reaction time. 6 Fig2. See the enlarged ventricles [] 2.2A.DSM-IV . diagnostic criteria. DSM-IV diagnostic criteria for schizophrenia A. Characteristic Symptoms Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated); (1) delusions (2) hallucinations (3) disorganized speech (e.g. frequent derailment or incoherence) (4) grossly disorganized or catatonic behavior (5) negative symptoms, that is, affective flattening, alogia, or avolition. Note: Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other. B. Social/occupational dysfunction For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal academic, or occupational achievement). C. Duration Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e. active phase symptoms) and may include periods of prodromal or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g. odd beliefs, unusual perceptual experiences). D. Schizoaffective and Mood Disorder exclusion Schizoaffective Disorder and Mood Disorder With Psychotic Features have been ruled out because either (1) no Major Depressive, Manic or Mixed Episodes have occurred concurrently with the active-phase symptoms, or (2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods. E. Substance/general medical condition exclusion The disturbance is not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition. F. Relationship to a Pervasive Developmental Disorder If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated). 7 [] 2.2B.Positive and Negative symptoms. -Positive signs : Positive symptoms are excesses in behavior (excessive function/distortions). -Negative symptoms : Negative symptoms are deficits in behavior (reduced function; self care deficits) Positive Delusion Hallucination. Disorganized thinking. Disorganized behaviors. Catatonic behaviors. Excitement or agitation. Possible suicidal tendencies. 8 Negative Avolition ( withdrawal behaviors ). Anhedonia ( loss of feeling or an inability to experience pleasure ) Alogia ( poverty of speech ) Flat presentation , poor or no eye contact , unchanged facial expressions. Difficulty in abstract thinking. Anergia (lack of energy) [] 2.3-Classification of Subtypes of Schizophrenia The Diagnostic and Statistical Manual of Mental Disorders 4 Text Revision have diagnostic criteria according to the subtypes of the disorder which are : Paranoid. [295.30] Catatonic.[295.20] Disorganized.[295.10] Undifferentiated.[295.90] Risdual.[295.60] 2.3A. Paranoid: Preoccupation with one or more delusions or frequent auditory hallucinations None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect patients exhibiting paranoid schizophrenia tend to experience persecutory or grandiose delusions. They also may exhibit behavioral changes such as anger, hostility, or violent behavior. Clinical symptoms may cause a threat to the safety of self or others. CLINICAL EXAMPLE.1 The Client With Schizophrenia, Paranoid Type BW, a 35-year-old mechanic, was brought to the admissions office by his wife because he had exhibited strange behavior for several months. He accused his wife of poisoning his food, spending all his money, having an affair with his boss, and telling stories about him. He displayed no facial expressions during his initial interview and became quite argumentative when questioned about his job. At the end of the interview, BW confided in the interviewer that he had been receiving messages from Jesus Christ while watching television. 9 [] 2.3B.Catatonic: At least two of the following are present: Motor immobility ,waxy flexibility, or stupor. Excessive motor activity that is purposeless. Extreme negativism or mutism. Peculiarities of voluntary movement as evidenced by posturing, stereotyped movements, prominent mannerisms or prominent grimacing. Echolalia (repeats all words or phrases heard) or echopraxia (mimics actions of others) Patients are at risk medically because of extreme withdrawal, which can result in a vegetative condition or excessive motor activity that could produce exhaustion or selfinflicted injury. CLINICAL EXAMPLE.2 The Client With Schizophrenia, Catatonic Type CS, a 25-year-old engineer, was admitted to the hospital as result of dehydration because of refusing to eat. During his hospitalization, CS was negativistic, refusing nursing care, food, and medication. He rarely spoke and assumed uncomfortable positions in bed for long periods. When placed in various positions by the nurse during the morning bath or shower, CS remained in the positions until the nurse changed them. He also exhibited purposeless movements of his hands and feet while sitting in a chair. 10 [] 2.3C.Disorganized : All of the following are prominent and criteria are not met for catatonic type: Disorganized speech Disorganized behavior Flat or inappropriate affect The criteria are not met for the catatonic type. The behavior disorganization may lead to sever disruption in the ability to perform activities of daily living . And one of the associated symptoms could be mannerisms and grimace . CLINICAL EXAMPLE .3 The Client With Schizophrenia, Disorganized Type MJ, a 19-year-old waitress, was seen in the admitting office of a psychiatric hospital. During the initial interview, she giggled inappropriately. Her long, uncombed hair fell over her face, concealing her facial expressions. She mumbled incoherently at times and displayed the behavior of a 13- or 14-year-old adolescent. She complained of numerous aches and pains and stated that voices told her she was being punished for not cleaning her room. MJ's mother stated that she remained in her room at home and did not socialize with friends. Her parents sought help when they noticed her behavior regressing during the past 2 months. 11 [] 2.3D.Undeffrentiated: The patient could have both of negative and positive signs of schizophrenia , also delusion , hallucination , in addition to bizarre or add behavior . The most important note to be in consideration is that the criteria are not met for the paranoid , disorganized , or catatonic type. 2.23.Risdual : Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized or catatonic behavior Continuing evidence of, in attenuated form, the presence of negative symptoms or two or more symptoms of diagnostic characteristics Is labeled on the patient who have at least one episode of schizophrenia but currently does not have noticeable positive signs , the disturbance is indicated by the presence of negative signs. The patient may have some positive signs but its not prominent and not accompanied by strong affect . 12 [] 3.1.Treatment and Therapy A.Pharmacological treatments : Antipsychotic drugs are used in schizophrenia management , antipsychotic drugs are not a homogeneous group, and there are various classes. There is the typical ones , or what so called “first generation” also the newer atypical or “second generation“ Below is a table show the most common medication from both types and further details about some of it . Type Class Example Typical antipsychotics Phenothiazines Chloropromazine, Thioridazine Trifluoperazine, Fluphenazine Butyrophenones Haloperidol, Droperidol Thioxanthenes Flupenthixol, Zuclopenthixol Diphenylbutylpiperidines Pimozide, Fluspiraline Dibenzodiazepines Clozapine Benzixasoles Risperidone, iloperidone Dibenzothiazepines Quetiapine Thienobenzodiazepines Olanzapine Imidazolidinones Sertindole Benzothiazolylpiperazines Ziprasidone Substituted benzamides amisulpride, sulpiride sulpiride is considered by some to be a typical antipsychotic Quinolinones Aripiprazole Atypical antipsychotics 13 [] ** Detailed information about some of the antipsychotic drugs : Olanzapine: -indication: Short and long term management of schizophrenia. Mono therapy in acute mixed , manic episode of bipolar disorder. -Contraindication : Lactation. -side effect : Nuroleptic malignant syndrome . Dyskinesia (involuntary, repetitive movements) Increased salivation. Haloperidol : -indication: Prolonged therapy in chronic schizophrenia Sever behavior problem in children with explosive hyperexcitability . -contraindication : Use with extra caution or not at all with parkinsonism or lactation . -side effect : Akathisia.( feeling of inner restlessness and a compelling) Dystonia.( muscle contractions cause twisting and repetitive movements or abnormal postures) 14 [] B.Psychological therapy: Psychoanalytic psychotherapies have largely been discredited in the management of schizophrenia, and indeed cast something of a shadow over the development of more effective approaches to treatment. However, a number of very promising new approaches are now emerging. Cognitive behavioral therapy Cognitive behavioral therapy (CBT) encompasses a variety of interventions. At its core is the idea that if patients can be presented with a credible ‘cognitive’ model of their symptoms, they may develop more adaptive coping strategies, leading to reduced distress, improved social function and possibly even symptom reduction. CBT involves regular one-to-one contact over a defined time period between patient and therapist. Family treatments Family therapy in schizophrenia is based on a ‘psycho-educational’ approach which includes information about the nature of the disorder, its treatment, and factors which might modify its course. It appears to have a modest effect in reducing the risk of relapse in schizophrenia. 15 [] Care Plan For Patient with Schizophrenia 16 [] W ASSESSMENT hen assessing schizophrenic patient, you might have difficulties because of the presence of psychotic symptoms. use of assessment tools such a “Positive and Negative Syndrome Scale” , may or may not be useful for collecting data about orientation, memory, thought and perceptual processes, intellectual function, judgment, insight, affect, and mood. So to collect data more correctly, its more professional to collect the data from : Family members or relatives if present. Health worker who take the care of the patient. Patient file . Patient him self if he is cooperative. During assessment phase , collect data concerns the following : Personal data . History of psychiatric illness. The schizophrenic patients share some findings like : Hallucinations. Delusions. Self care deficits. Decreased medication compliance . Sleep problems. Isolation and withdrawal. start gathering data according to physical , mental and social aspects in the basis of : physical dimension. Emotional dimension. Intellectual dimension Social dimension. Spiritual dimension. Further details will be attached to the project . Assessment findings is individualized for every patient , some could have chronic illnesses like DM , hypertension, or other organic disease beside to mental disease. 17 [] Diagnoses The needs of patients will be interpreted in the following nursing diagnoses : Disturbed thought processes related to the presence of delusions. Disturbed sensory perception related to the presence of hallucinations. Self-care deficit related to poor personal hygiene. Impaired verbal communication related to thought disturbance (looseness of association). Noncompliance related to refusal to take prescribed psychotropic medication. Disturbed sleep pattern related to the presence of auditory hallucinations. Social isolation related to fear or homelessness. Ineffective coping related to fear. Risk for Violence: Self-directed or Other-directed related to suspicion and inability to recognize people or places. Planning and Outcomes Identification The patient problems were identified and the next step is to set the goals appropriate for each patient in order to increase health , maintain it or prevent further deteriorations. In schizophrenic patient , planning for the care needed most take holistic approach , so The desired results and outcomes reached , and these are examples of goals based on the diagnosis mentioned above : The patient will communicate with members of the treatment team. The patient will verbalize his or her physical needs. The patient will have compliance with medication management. The patient will demonstrate the ability to perform personal hygiene on a daily basis with minimal assistance or prompting. The patient will verbalize a decrease in the frequency of hallucinations. The patient will verbalize a decrease in the presence of the delusions. The patient will show an increase in the ability to socialize. The patient will exhibit an accurate perception of reality. The patient will not harm others or self and remain safe from injuries . 18 [] Implementation \ intervention This is were actions take place , and its time to focus on establishing a trusting relationship, establishing clear, consistent, open communication, providing a safe environment, alleviating positive, negative, and disorganized symptoms, and maintaining biologic integrity by dealing with each given problem in therapeutic way. Now , a set of interventions will be assigned for most common diagnosis so it can achieve the desired outcomes . Diagnosis :Disturbed thought processes related to the presence of delusions. Outcome: The patient will verbalize a decrease in the presence of the delusions. Intervention : Do not argue with the client or attempt to disprove delusional or suspicious thoughts. interject doubt if its appropriate. Do not whisper or laugh in the presence of the patient ( for suspicious patient and persecutory ). If the patient asks you if you believe the delusion, inform the client that you do not share the perception or delusional belief. Identify ways to help the patient control thoughts... Such as distracting oneself from thinking the same thought repeatedly, using thoughtswitching techniques, identifying signs, such as staring, that indicate thoughts are becoming disorganized; and anticipating new situations that may increase anxiety or enhance delusional thoughts. Encourage the patient to discuss the logic or reasoning behind the delusion. 19 [] Diagnosis : Disturbed sensory perception related to the presence of hallucinations. Outcome : The patient will verbalize a decrease in the frequency of hallucinations. Intervention : Interrupt patient hallucination by simply starting dialogue or assign simple task to make him busy and within reality. Attempt to identify precipitating factors by asking the patient what happened prior to the onset of hallucinations. Decrease environmental stimuli such as loud music, extremely bright colors, or flashing lights. Monitor for command hallucinations that may precipitate aggressive or violent behavior. Diagnosis : Social isolation related to fear or homelessness Outcome : The patient will show an increase in the ability to socialize. Intervention : Build relationship with the patient based on trust and respect. Try to start therapeutic communication with the patient , select appropriate time . Find and discuss with patient ways to spend his day . Ask the patient to engage in the ward activity with other patient , like bed making preparations . plan for a schedule with treatment team to assign the patient in social rehabilitation programs such as work therapy and play therapy . 20 [] Diagnosis: Self-care deficit related to poor personal hygiene low nutrition intake. Outcome : The patient will demonstrate the ability to perform personal hygiene on a daily basis with minimal assistance or prompting and maintain proper weight and physical conditions. Intervention : Ensure that the patient takes bath at daily basis or 2\1 day . Make it habitual to ask the patient about his nails , hair , and teeth and care about them. Use clothing with elastic and Velcro for fastenings rather than buttons or zippers, which may be too difficult for patient to manipulate. Assess and monitor patient's ability to perform ADLs (activity of daily life ). Give a positive reinforcement for good grooming and dress. Monitor food and fluid intake. Sit with patient during meals and assist him. Weigh patient weekly. Diagnosis : Impaired verbal communication related to thought disturbance. Outcome : The patient will communicate with members of the treatment team. Intervention : Speak slowly and use short, simple words and phrases. If patient becomes aggressive, shift the topic to a safer, more familiar one. If patient becomes delusional, acknowledge feelings and reinforce reality. Do not attempt to challenge the content of the delusion. Use silence and at the same time keep in control of the discussion . Reassure the patient so he can take his time while he is communicate with you , and always try to make him in focus in the subject of the dialogue. 21 [] Evaluation The purpose of evaluation is “to compare the patient’s current mental status with stated desirable outcomes identified”. If the outcomes have not been met, consider the reasons why?.. For example, outcomes may not be achieved due to: the patient's lack of belief in success. unrealistic expectations regarding recovery. Lack of social support or income. cognitive deficit that limits the patient's insight regarding his or her illness. Depression may occur due to a decline in dopamine level as the patient ages. Additional specific nursing interventions and changes in outcomes may be necessary. ● ● ● Its important to understand and recognize that is the nursing process it’s DYNAMIC, change as the patient status changes , further assessment must be done , and the care have to continue as the patient deals with any problems on his mental-social-physical and environmental status . ● 22 ● ● [] REFERENCES : -Mario Maj ,Norman Sartorius. "Schizophrenia" ,2nd edition ,(2002) -Martin Stefan , Mike Travis , Robin M. Murray. "An Atlas of SCHIZOPHRENIA" ,(2002) -ELLEN THACKERY ,MADELINE HARRIS ,"The GALE ENCYCLOPEDIA of MENTAL Disorders", (2003) -Miles Hewstone, Frank D. Fincham ,Jonathan Foster, "Psychollogy" , (2005) -Darlene D. Pedersen , "Psych Notes - Clinical Pocket Guide " , (2005) -American Psychatric Acociation , "DSM-IV-TR" Dignostic and statistical manual of mental disorder , fourth eddition ,text revision , (2000) -Shives, Louise Rebraca , "Basic Concepts of Psychiatric-Mental Health Nursing", 6th Edition ,(2005) -Nettina, Sandra M.; Mills, Elizabeth Jacqueline , "Lippincott Manual of Nursing Practice", 8th Edition , (2006) -George R.spratto , adrienne L.Woods , "PDR NURSES DRUG HANDBOOK" , 2007 Edition , (2007) 23